Stat consult: Minor burns

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The most common causes of minor superficial burns are sunburns and minor thermal injuries.
The most common causes of minor superficial burns are sunburns and minor thermal injuries.

Description

  • injury with necrosis of epidermis and dermis after thermal, chemical, electrical, or radiation exposure

Types

  • first-degree (epidermis only)
  • second-degree (through epidermis and into dermis)
    • superficial
    • deep
  • third-degree (all layers of skin including subcutaneous fat)

Who is most affected

  • children and elderly patients

Possible risk factors

  • increased age
  • drug and/or alcohol abuse
  • photosensitizer medication use, including
    • amiodarone
    • chlorpromazine
    • hydrochlorothiazide
    • antibiotics (nalidixic acid, fluoroquinolone, doxycycline, tetracycline, voriconazole)naproxen
    • piroxicam
    • retinoids
  • for children < 5 years old, access to hot liquids without adult supervision

Causes

  • most common causes of superficial burns
    • sunburn
    • minor thermal injury
  • causes of thermal burns
    • scalds
      • in children
        • 70% to 80% of burns
        • hot liquid, steam, spill, or immersion
        • warm air humidifier
      • in adults
        • hot food, water and steam in patients ≥ 65 years old
        • hot bath water
    • fire (flame or flash)
      • about 50% of adult burns
      • associated with trauma or inhalation injury
    • contact with hot surfaces
  • causes of chemical burns
    • acids
    • alkalis
    • petroleum products
    • phosphorous
    • airbags
    • hair dyes
    • fabric detergents
  • causes of radiation burns
    • sunburn
    • industrial electromagnetic and particle radiation
  • electrical burn
    • may be high voltage, low voltage, or flash

History

Chief concern (CC)

  • pain
History of present illness (HPI)
  • assess risk for
    • concomitant injury
    • inhalation injury
  • if non-accidental injury suspected in a child, check for inconsistencies in histories

Medication history

  • ask about use of photosensitizing drugs

Physical

Skin

  • determine depth of burn
  • first-degree burn
    • tenderness
    • dry erythema without blisters
    • brisk capillary refill with pressure
    • brisk bleeding with 21-gauge needle pin prick
  • second-degree burn
    • superficial partial-thickness (second-degree) burn
      • tenderness
      • blanching with pressure
      • wet, weeping, erythematous skin
      • clear blisters
      • usually pink but may be white
      • brisk bleeding with 21-gauge needle pin prick
    • deep partial-thickness burn

no sensitivity to touch or dull sensation

white or fixed red coloration

non-blanching with pressure

blisters

delayed bleeding with 21-gauge needle pin prick

  • third-degree (full-thickness) burn
    • no sensitivity to touch
    • dark brown, tan, or white with leathery feel
    • may be charred and dry or hard and waxy
    • no blisters
    • no blanching with pressure, capillary refill
    • no bleeding with pin prick
  • estimate body surface area (BSA) affected for second- and third-degree burns
    • Lund-Browder chart of body surface
      • most accurate 
      • estimated BSA
        • neck
          • anterior 1%
          • posterior  1%
        • trunk
          • anterior 13%
          • posterior 13%
        • upper arm
          • each posterior 2%
          • each anterior 2%
        • lower arm
          • each anterior 1.5%
          • each posterior 1.5%
        • each buttock 2.5%
        • genitalia 1%
        • foot
          • each top 1.75%
          • each bottom 1.75%
        • age-based variable percentages for
          • each half of head
          • each half of 1 thigh
          • each half of lower leg
    • Wallace rule of nines
      • fast estimate of medium to large burns in adults
      • estimated total BSA in adults
        • head 9%
        • anterior trunk 18%
        • posterior trunk 18%
        • each upper extremity 9%
        • each lower extremity 18%
        • genitalia 1%
    • palmar surface measurement
      • assumes palmar surface of patient's hand is about 0.8% of total BSA for adults and about 1% of total BSA for children
      • useful for estimation of
        • small burns (< 15% total BSA
        • small unburned areas in cases of major burn (> 85% total BSA)
      • inaccurate for medium sized burn

Making the diagnosis

  • clinical diagnosis with history of exposure and findings of injured or necrotic skin
  • criteria for minor burns
    • first-degree burns
    • second-degree burns affecting
      • 5% of total BSA in patients < 10 years old or > 50 years old
      • 10% of total BSA in patients aged 10 to 50 years
    • third-degree burns  < 1% of total BSA
    • for second- and third-degree burns
      • no involvement of face, hands, perineum, genitals, or feet
      • no crossing of a major joint
      • not circumferential
    • no concomitant injury or severe trauma
    • no comorbidity

Differential diagnosis

  • phytocontact dermatitis
    • mustard seed
    • buttercup
  • other mimics
    • leukemia cutis
    • toxic epidermal necrolysis
    • pressure necrosis

Testing overview

  • no additional testing required

Treatment overview

  • for first-degree (superficial) burns
    • moist environments
    • topical agents and dressings
    • comparative efficacy
      • studies generally of poor quality
      • insufficient evidence to determine superiority of any single burn dressing
  • for treatment of second-degree (partial-thickness) burns
    • indications for referral to burns specialist
      • unlikely to heal within 3 weeks (deep partial-thickness or full-thickness )
      • partial-thickness burns > 10% of total BSA or > 5% in children < 16 years old
      • worsening over first 72 hours (increased depth or signs of infection)
      • not healed within 2 weeks
    • consider blister management and debridement
      • no consensus and limited clinical evidence for management
      • suggestions for blister management for partial-thickness burns
        • leave intact if
          • blisters < 6 mm
          • larger blisters on palms or soles not restricting movement
        • debride if
          • blisters > 6 mm
          • prevent joint movement or likely to rupture
        • keep debrided wound moist with topical dressing
    • use occlusive dressing or topical agent
      • non-silver dressings
        • insufficient evidence to support superiority of any type for superficial and partial-thickness burns
        • associated with faster healing times compared to silver sulfadiazine
      • silver sulfadiazine in cream or dressing associated with higher rates of infections in burns compared to other dressings
  • pain control as needed,
  • tetanus booster if > first-degree burn
  • if non-accidental injury suspected in a child, immediately notify social services
  • refer to burns specialist or reconstructive surgeon if
    • significant scarring
    • any contracture

Complications

  • infection
  • hypo or hyperpigmentation
  • respiratory-related hospital admission

Prognosis

  • usual time to healing
    • superficial burn, about 3 to 10 days
    • superficial partial-thickness burn, about 2 weeks
    • deep partial-thickness burn, ≥ 3 weeks

Prevention

  • evidence-based prevention strategies
    • in infants and children
      • properly installed and maintained smoke detectors
      • water heater temperature preset to < 130° F (54.4° C)
      • clinical counseling to increase smoke detector use
    • for sunburn
      • SPF 40 sunscreen more effective than SPF 12
      • topical aloe vera cream likely not effective 

Dr. Drabkin is a senior clinical writer for DynaMed (www.ebscohost. com/dynamed), a database of comprehensive updated summaries covering more than 3,200 clinical topics, and assistant clinical professor of population medicine at Harvard Medical School.

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